Wednesday, September 8, 2010

Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose, and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis

Causes Bronchiectasis
The primary etiology in the development of ordinary acquired Bronchiectasis is inflammatory destruction of the elastic tissue, smooth muscle, and cartilage of bronchial walls usually due to severe preceding infection(s). Fewer cases are caused by genetic or immune deficiencies or result from inhalation injury. Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:

Predisposing factors:
Bronchopulmonary infection— Mycobacterium species, bacterial (e.g., Staphylococcus aureus, Bordetella pertussis, Klebsiella pneumoniae, H. influenza ), viral (e.g., measles, HIV, adenovirus, influenza), fungal (histoplasmosis, coccidiomycosis), recurrent aspiration pneumonia. Bronchial obstruction—foreign body aspiration, lung or bronchogenic neoplasm, airway nodules, hilar adenopathy (e.g., sarcoidosis), mucus impaction (e.g., allergic bronchopulmonary aspergllosis), broncholith, external compression by vascular aneurysm. Immunodefi ciency states—hypogammaglobulinemia, IgG subclass deficiency, selective IgA deficiency. Other congenital syndromes—cystic fibrosis, alpha1-antitrypsin deficiency, primary ciliary dyskinesia (e.g., Kartagener’s syndrome), Young’s syndrome (azoospermia and chronic sinopulmonary infections). Inhalation injury—smoke, ammonia, sulfur or nitrogen dioxide. Rheumatologic disease—rheumatoid arthritis, Sjogren’s syndrome Anatomic defects—bronchomalacia, Swyer-James syndrome, bronchial cartilage deficiency (Williams-Campbell syndrome), tracheobronchomegaly (Mounier-Kuhn syndrome)

Complications Bronchiectasis
Hemoptysis occurs in nearly 50% of patients with bronchiectasis (Mysliwiec & Pina, 1999); major pulmonary hemorrhage and death from exsanguination are rare (Swartz, 1998). Empyema, lung abscess, and pneumothorax are serious but rare complications of acute infections in bronchiectasis (Luce, 1994). Progressive respiratory insuffi ciency and cor pulmonale complicate severe bronchiectasis associated with deteriorating pulmonary function and hypoxemia.

Medical interventions 
Inhaled bronchodilators may be helpful in diffuse small airway disease; beta adrenergic agents dilate airways and improve ciliary activity (Swartz, 1998).
Antimicrobial therapy for treatment of acute infectious exacerbations is based on results of sputum gram stain and culture. Corticosteroids reduce the airway infl ammatory response in bronchiectasis. Oxygen therapy is prescribed as indicated for patients with hypoxemia at rest, during sleep, and/or with activity. Gamma globulin replacement for immunoglobulin defi ciency may be effective in reducing the frequency and severity of sinopulmonary infections (George et al., 1995). Effective reduction and removal of bronchial secretions by a variety of available methods is critical in patients with bronchiectasis. The approach selected should be based upon an individual’s self-care abilities, motivation, breath control, neuromuscular status, preferences, needs, and financial resources (Langenderfer, 1998). Effective cough Percussion and postural drainage Autogenic drainage Positive expiratory pressure (PEP) therapy Flutter valve Vest therapy Humidifi cation (by cold water, jet nebulizers) as an adjunct to chest physiotherapy enhanced sputum production (Conway, Fleming, Perring, & Holgate, 1992). Aerosolized recombinant human DNase may lyse the DNA that causes the sputum to be highly viscous. Initial studies for cystic fibrosis are promising, but this therapy is not FDA approved in non-CF bronchiectasis (O’Donnell, Barker, Ilowite, & Fick, 1998; Wills et al., 1996). Non-invasive intermittent positive pressure ventilation (NIPPV) is an alternative to tracheostomy for respiratory failure due to advanced bronchiectasis.

Surgical intervention
Surgical resection
Lung or heart-lung transplantation

Nursing assessment for Bronchiectasis 
Patient’s history of recurrent bronchopulmonary infections and symptoms of chronic productive cough are hallmark features of bronchiectasis. Pain and dyspnea are also common. The history of acute, even if delayed, onset of bronchiectasis can sometimes be traced to a defi nite illness, pneumonia, or aspiration event in patients with postobstructive or infectious bronchiectasis. Those patients with underlying congenital or immune disorders usually demonstrate a more insidious disease onset (Luce, 1994). Cough is present in 90% of patients (Nicotra et al., 1995). Daily (often purulent) sputum production occurs in 75% of patients and varies in volume from 10–500 ml (Nicotra et al., 1995). Pleuritic chest pain represents distended peripheral airways or distal pneumonitis adjacent to a visceral pleural surface. This symptom occurs in 50% of bronchiectasis patients (Barker, 2002). Repeated episodes of fever, pleurisy, and/or sinusitis are also common. Weakness, dyspnea, and weight loss are seen in patients during infectious exacerbations or those with extensive disease. The St. George’s Respiratory Questionnaire (SGRQ) has been validated as a useful tool for assessment of health-related quality of life in patients with bronchiectasis (Wilson, Jones, O’Leary, Cole, & Wilson, 1997). Test items are divided into three major areas: symptomatology; activity tolerance; and impact of the condition on daily life including employment, need for medications, and sense of control or panic over one’s health.
Physical examination findings are neither sensitive nor specific for bronchiectasis. Crackles are the most common adventitious auscultatory finding, followed in frequency by wheezing, rhonchi, and a pleural friction rub (Barker, 2002; Mysliwiec & Pina, 1999; Nicotra et al., 1995). Digital clubbing is rare (Barker, 2002; Mysliwiec & Pina, 1999). Nasal polyps and sinusitis may also be evident (Luce, 1994). Patients may have fetid breath chronically or solely during episodes of purulent sputum production. Generalized weight loss and use of accessory muscles accompany severe disease.

Diagnostic Test for Bronchiectasis 
Radiographic imaging studies are the principal diagnostic tools for Bronchiectasis (chest roentgenogram, non-contrast computed tomography (HRCT) and spiral volumetric scans.
Bronchoscopy is used to examine airways for obstructing tumors or foreign bodies, to evaluate the degree and site of hemoptysis, and to detect or remove inspissated secretions (Barker & Bardana, 1988; George, Matthay, Light, & Matthay, 1995).
Functional assessment of the bronchiectasis patient includes pulmonary function testing with spirometry and lung volumes, and arterial blood gas analysis.
Laboratory studies are important in the diagnosis and follow-up of patients:

  • The complete blood count with cell differential may reveal leukocytosis or increased neutrophil levels during acute exacerbations; anemia may be present in chronic infections (Swartz,1998). 
  • Quantitative serum immunoglobulin levels of IgA, IgM, IgE, IgG 
  • Sputum smear reveals large numbers of white blood cells and both gram-positive and gram-negative organisms 
  • Sweat chloride testing is used to screen for cystic fibrosis in young adults with no identifiable predisposing cause for bronchiectasis. 
  • Aspergillus titers are indicated when an Aspergillus organism is cultured or if radiographic exam (chest X-ray or HRCT) demonstrates central bronchiectasis (Barker & Bardana, 1988). 

Nursing Diagnosis That Could Be Found In Patient with Bronchiectasis
Common nursing diagnosis found in nursing care plans for Bronchiectasis:

  • Impaired gas exchange related to ventilation–perfusion inequality 
  • Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications 
  • Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants 
  • Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation 
  • Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns 
  • Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work 
  • Deficient knowledge about self-management to be performed at home. 

Sample nursing care plans Bronchiectasis:
Impaired gas exchange related to ventilation perfusion inequality

a.    Administer bronchodilators as prescribed:
·      Inhalation is the preferred route.
·      Observe for side effects: tachycardia, dysrhythmias, central nervous system excitation, nausea, and vomiting.
·      Assess for correct technique of metered-dose inhaler (MDI) administration.

b.  Evaluate effectiveness of nebulizer or MDI treatments.
·      Assess for decreased shortness of breath, decreased wheezing or crackles, loosened secretions, decreased anxiety.
·      Ensure that treatment is given before meals to avoid nausea and to reduce fatigue that accompanies eating.

c.    Instruct and encourage patient in diaphragmatic breathing and effective coughing.

d.    Administer oxygen by the method prescribed.
·      Explain rationale and importance to patient.
·      Evaluate effectiveness; observe for signs of hypoxemia. Notify physician if restlessness, anxiety, somnolence, cyanosis, or tachycardia is present.
·      Analyze arterial blood gases and compare with baseline values. When arterial puncture is performed and a blood sample is obtained, hold puncture site for 5 minutes to prevent arterial bleeding and development of ecchymoses.
·      Initiate pulse oximetry to monitor oxygen saturation.
·      Explain that no smoking is permitted by patient or visitors while oxygen is in use.
a.    Bronchodilators dilate the airways. The medication dosage is carefully adjusted for each patient, in accordance with clinical response.

b.    Combining medication with aerosolized bronchodilators is typically used to control bronchoconstriction in an acute exacerbation. Generally, however, the MDI with spacer is the preferred route (less cost and time to treatment).

c.    These techniques improve ventilation by opening airways to facilitate clearing the airways of sputum. Gas exchange is improved and fatigue is minimized.

d.   Oxygen will correct the hypoxemia. Careful observation of the liter flow or the percentage administered and its effect on the patient is important. If the patient has chronic CO2 retention, excessive oxygen could suppress the hypoxic drive and respirations. These patients generally need low-flow oxygen rates of 1 to 2 L/min. Periodic arterial blood gases and pulse oximetry help to evaluate adequacy of oxygenation. Smoking may render pulse oximetry inaccurate because the carbon monoxide from cigarette smoke also saturates hemoglobin.

1.    Verbalizes need for bronchodilators and for taking as prescribed
2.    Evidences minimal side effects; heart rate near normal, absence of dysrhythmias, normal mentation
3.    Reports a decrease in dyspnea
4.    Shows an improved expiratory flow rate
5.    Uses and cleans respiratory therapy equipment as applicable
6.    Demonstrates diaphragmatic breathing and coughing
7.    Uses oxygen equipment appropriately when indicated
·         Evidences improved arterial blood gases or pulse oximetry
·         Demonstrates correct technique for use of MDI

Ineffective airway clearance related to bronchoconstriction, increased mucus production,
ineffective cough, bronchopulmonary infection, and other complications 
a.     Adequately hydrate the patient.

b.     Teach and encourage the use of diaphragmatic breathing and coughing techniques.

c.    Assist in administering nebulizer or MDI.

d.    If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed.

e.    Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes.

f.     Teach early signs of infection that are to be reported to the clinician immediately:
1.      Increased sputum production
2.      Change in color of sputum
3.      Increased thickness of sputum
4.      Increased shortness of breath, tightness in chest, or fatigue Increased coughing
5.      Fever or chills
      g.       Administer antibiotics as prescribed.

        h.      Encourage patient to be immunized
against influenza and Streptococcus pneumoniae. 
a.    This ensures adequate delivery of medication to the airways.

b.    Uses gravity to help raise secretions so they can be more easily expectorated or suctioned.

c.    Bronchial irritants cause bronchoconstriction and increased mucus production, which then interferes with airway clearance.
d.   Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. Early recognition is crucial.
e.    Antibiotics may be prescribed to prevent or treat infection.

f.    People with respiratory conditions are prone to respiratory infections and are encouraged to be immunized.
1.     Verbalizes need to drink fluids
2.     Demonstrates diaphragmatic breathing and coughing
3.     Performs postural drainage correctly
4.     Coughing is minimized
5.     Does not smoke
6.     Verbalizes that pollens, fumes, gases, dusts, and extremes of temperature and humidity are irritants to be avoided
7.     Identifies signs of early infection
8.     Is free of infection (no fever, no change in sputum, lessening of dyspnea)
9.     Verbalizes need to notify health care provider at the earliest sign of infection
10. Verbalizes need to stay away from crowds or people with colds in flu season
11. Discusses flu and pneumonia vaccines with clinician to help prevent infection

Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction,
and airway irritants
a.     Teach patient diaphragmatic and pursedlip breathing.

b.     Encourage alternating activity with rest periods. Allow patient to make some decisions (bath, shaving) about care based on tolerance level.
c.     Encourage use of an inspiratory muscle trainer if prescribed.
a.    Helps patient prolong expiration time and decreases air trapping. With these techniques, patient will breathe more efficiently and effectively.
b.   Pacing activities permits patient to perform activities without excessive distress.

c.    Strengthens and conditions the respiratory muscles.
1.     Practices pursed-lip and diaphragmatic breathing and uses them when short of breath and with activity
2.     Shows signs of decreased respiratory effort and paces activities
3.     Uses inspiratory muscle trainer as prescribed
Self-care deficits related to fatigue secondary to increased work of breathing and insufficient
ventilation and oxygenation
a.    Teach patient to coordinate diaphragmatic breathing with activity (eg, walking, bending).

b.    Encourage patient to begin to bathe self, dress self, walk, and drink fluids. Discuss energy conservation measures.

c.    Teach postural drainage if appropriate.
a.    This will allow the patient to be more active and to avoid excessive fatigue or dyspnea during activity.
b.   As condition resolves, patient will be able to do more but needs to be encouraged to avoid increasing dependence.
c.    Encourages patient to become involved in own care. Prepares patient to manage at home.
1.    Uses controlled breathing while bathing, bending, and walking
2.    Paces activities of daily living to alternate with rest periods to reduce fatigue and dyspnea
3.    Describes energy conservation strategies
4.    Performs same self-care activities as before
5.    Performs postural drainage correctly

Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns
a.     Support patient in establishing a regular regimen of exercise using treadmill and exercycle, walking, or other appropriate exercises, such as mall walking.
1.    Assess the patient’s current level of functioning and develop exercise plan based on baseline functional status.
2.    Suggest consultation with a physical therapist or pulmonary rehabilitation program to determine an exercise program specific to the patient’s capability. Have portable oxygen unit available if oxygen is prescribed for exercise.
a.    Muscles that are deconditioned consume more oxygen and place an additional burden on the lungs. Through regular, graded exercise, these muscle groups become more conditioned, and the patient can do more without getting as short of breath. Graded exercise breaks the cycle of debilitation.
1.     Performs activities with less shortness of breath
2.     Verbalizes need to exercise daily and demonstrates an exercise plan to be carried out at home
3.     Walks and gradually increases walking time and distance to improve physical condition
4.     Exercises both upper and lower body muscle groups
Ineffective coping related to reduced socialization, anxiety, depression, lower activity level,
and the inability to work
  1. Help the patient develop realistic goals.

  1. Encourage activity to level of symptom tolerance. 
  1. Teach relaxation technique or provide a relaxation tape for patient.
  1. Enroll patient in pulmonary rehabilitation program where available.
     a.       Developing realistic goals will promote a sense of hope and accomplishment rather than defeat and hopelessness.
     b.      Activity reduces tension and decreases degree of dyspnea as patient becomes conditioned.
     c.       Relaxation reduces stress, anxiety, and dyspnea and helps patient to cope with disability.
     d.      Pulmonary rehabilitation programs have been shown to promote a subjective improvement in a patient’s status and selfesteem as well as increased exercise tolerance and decreased hospitalizations.
1.    Expresses interest in the future
2.    Participates in the discharge plan
3.    Discusses activities or methods that can be performed to ease shortness of breath
4.    Uses relaxation techniques appropriately
5.    Expresses interest in a pulmonary rehabilitation program
Deficient knowledge about self-management to be performed at home.
a.     Help patient understand short- and longterm goals.
1.    Teach the patient about disease, medications, procedures, and how and when to seek help.
2.    Refer patient to pulmonary rehabilitation.

  1. Give strong message to stop smoking. Discuss smoking cessation strategies. Provide information about resource groups

a.    Patient needs to be a partner in developing the plan of care and needs to know what to expect. Teaching about the condition is one of the most important aspects of care; it will prepare the patient to live and cope with the condition and improve quality of life.
b.   Smoking causes permanent damage to the lung and diminishes the lungs’ protective mechanisms. Air flow is obstructed and lung capacity is reduced. Smoking increases morbidity and mortality and is also a risk factor for lung cancer.
1.     Understands disease and what affects it
2.     Verbalizes the need to preserve existing lung function by adhering to the prescribed program
3.     Understands purposes and proper administration of medications
4.     Stops smoking or enrolls in a smoking cessation program
5.     Identifies when and whom to call for assistance

Patient Teaching & Home Health Guidance 
Patient Teaching & Home Health Guidance for Patient With Bronchiectasis. Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis. 
Patient Teaching & Home Health Guidance for Patient with Bronchiectasis: 

  • Instruct on early signs of pulmonary or sinus infection: change in amount or color of sputum or nasal drainage, Hemoptysis, increased Dyspnea, fever, chills, fatigue, headache, chest pain. 
  • Emphasize importance of completing full course of antimicrobial therapy to prevent relapse or development of resistant strains of organisms; include education on proper delivery of intravenous and/or aerosolized antibiotics. 
  • Teach patient and significant other effective airway clearance techniques to remove secretions and optimize ventilation. In addition to postural drainage and chest percussion, the patient may be instructed on proper use of the Flutter or PEP devices. The Vest is an alternative to chest percussion. 
  • Encourage the patient to drink plenty of fluids to thin secretions and aid expectoration 
  • Educate on avoidance of potential lung irritants: secondhand smoke, dust, noxious fumes, occupational exposures, and respiratory infections. 
  • Instruct the patient to avoid air pollutants and people with known upper respiratory tract infections. 
  • Inform patient of variety of pharmacologic and non-pharmacologic smoking cessation strategies and aids. 
  • If appropriate, advise the patient to stop smoking because it stimulates secretions and irritates the airways.

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